Thursday, April 26, 2012

Solving the American health care system crisis is among the most complex and
important challenges facing this generation. Is it possible to provide
high quality care with better access at a more affordable cost? Is this
problem solvable or simply to complicated? Though that answer is not
yet clear, what is increasingly apparent is that a new type leadership
is needed if there is any hope in achieving this goal.
Professor Amy Edmondson of Harvard Business school has crafted a practical
evidenced based book on how leaders and organizations must approach the
increasing complexity of problems they face. Unlike the mindset of
execution, which was successful in the past, Professor Edmondson
demonstrates that in an increasingly competitive global economy a
different approach is needed.

Organizations must learn by teaming.

It is a must read for physician leaders or other leaders in health care.

She provides leaders a clear understanding of how individual and
organizational psychology, the reality of hierarchical status, cultural
differences, and distance can and do separate team members which can
prevent successful teaming. Leaders can close these gaps by
understanding the existence of these obstacles and by adapting their
leadership style to support and facilitate teaming successfully. She
demonstrates the challenges as well as the solutions where teaming has
gone well and not so well (the "impossible" rescue of miners in Chile
and space shuttle Columbia tragedy) with numerous case studies and
insights.

Professor Edmondson also notes that leaders
must also thoughtfully identify where the challenges they face fit on
the Process Knowledge Spectrum (routine, complex, or innovation).
Routine operations could be a car manufacturing plant where outcomes and
certainty are known. At the other extreme, innovation operations, like
an academic research lab, the outcomes and certainty are quite unknown.
Hospitals are considered complex operations. Although the teaming
framework applies in each of these three cases, the leader's specific
behaviors and actions change. Having excellent outcomes and teaming
necessitates matching the right approach to the correct operation.

Interestingly
to maximize learning, conflict and failure are necessary for teaming to
be successful. These can only occur if leaders create an environment of
psychological safety. Learning thoughtfully from these failures and
framing them as essential for continuous improvement and innovation is
key for organizations to benefit from teaming.

Most importantly, the learning never stops.

Professor Edmondson provides many examples from health
care as she has "spent an inordinate amount of time studying people in
hospitals." In one example, she notes how two of four cardiovascular
surgical teams studied successfully implemented Minimally Invasive
Cardiac Surgery (MICS) because of how the leader framed the challenge.
It was a shared learning experience. The other two teams failed because
they focused on the individual surgeon rather than on the team. For
doctors, being able to ask others for help is culturally difficult and
yet vitally important given the increasingly complexity of hospitals and
medical knowledge. She notes that the "single most powerful factor
explaining success" among the the four teams was how the leader framed
the challenge.

She notes that for 23 hospital ICU improvement teams, those most
successful in changing were those "who engaged in the interpersonal
learning behaviors crucial to teaming".

One of the three
case studies is about leading teaming in a complex operations at
Children's Hospital. The goal of Julie Morath, the chief operating
officer, was to harm no patients and achieve a 100 percent in patient
safety. She engaged her staff to solve the problems. She eliminated the
tendency of the medical culture to view and blame a medical error as the
fault of the individual. Instead via "blameless reporting", observers
merely communicated what they saw and analysis followed. aBy creating a
culture of psychological safety, the hospital learned from their
"accident" and explored ways to improve the their care. As a result, the
hospital became nationally recognized as a leader in patient safety.

"For
over a century, we've focused too much on relentless execution and
depended too much on fear to get things done. That era is over...human
and organizational obstacles to teaming and learning can be
overcome...Few of today's most pressing social problems can be solved
within the four walls of any organization, no matter how enlightened or
extraordinary... Generating ideas to solve problems is the currency of
the future; teaming is the way to develop, implement, and improve those
ideas."

Although at times, the conclusions from her
twenty years of research and observation seem counterintuitive, her
findings and stories woven into a actionable framework and structure
makes Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy compelling. It is destined to be a classic reference
for leaders today and in the foreseeable future as they lead their
colleagues and organizations into confronting and solving increasingly
complex problems and challenges.

Professor Edmondson hopes
that her book will enable organizations to execute at a higher level
only "when leaders empower, rather than control; when they ask the right
questions, rather than provide the right answers; and when they focus
on flexibility, rather than insistent on adherence... When people know
their ideas are welcome, they will offer innovative ways to lower costs
and improve quality, thus laying a more solid foundation for meaningful
work and organizational success."

Thursday, April 5, 2012

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU). The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care
better quality, the truth is doctors won't likely follow these
guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a
challenge for the medical profession to have all doctors wash their
hands correctly every patient every time, get immunized routinely against influenza, or even not
to prescribe antibiotics for coughs, colds, and bronchitis
due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's
income. Some on the list of Choosing Wisely, however, will.

Do not repeat colorectal cancer screening (by any method) for 10
years after a high-quality colonoscopy is negative in average-risk
individuals.

Yet, if a doctor does fewer colonoscopies, which is the
right thing to do, that also means his income will decrease. In the fee
for service reimbursement system, doing fewer procedures means fewer
things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"?

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

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